INTRODUCTION

Smoking is one of the biggest causes of preventable poor health and premature death, and kills more than 7 million people each year¹. Around half of smokers will die prematurely from a smoking-related illness²; and smoking has been long viewed as a public-health problem in countries around the world, including Scotland and China.

About twenty percent of Scottish adults were smokers in 2014, with similar rates for men and women, 23% and 21%, respectively³. Tobacco use is associated with about: a quarter of all deaths and 56,000 hospital admissions each year in Scotland⁴. China has a deep-rooted cigarette-smoking culture⁵, for which the last (2010) Global Adult Tobacco Survey revealed a smoking prevalence of 52.9% and 2.4%, among males and females, respectively⁶. Among rural migrants to urban locations in China, the prevalence in 2016 was more than double for females at 5.3% and lower for males at 46.7%⁶.

The 2012 UK Integrated Household Survey (IHS) and 2012 GP Patient Survey (GPPS) indicated that cigarette smoking in the UK’s Chinese population was 17%-21% for males and 6%-7% for females⁷. Smoking prevalence among 493 members of Glasgow’s Chinese community showed male and female prevalence to be 21.9% and 1.6%, respectively⁸. Chinese immigrants across the world have been observed to smoke less than their counterparts in China^9,10.

The Chinese government has advised that smoking be prohibited⁵ in public places, such as restaurants, bus stations, parks and offices. However, China has yet to meet the WHO Framework Convention on Tobacco Control (FCTC) guidelines¹¹. Smoking initiation and maintenance is heavily influenced by: relatives’ smoking¹², peer influence¹³, culture¹⁴, and genetic and environmental factors¹⁵. In the UK, attention to individual health, setting an example for children, and smoking expenditure, are amongst the top three motives for smoking cessation^16,17. It is widely accepted that certain socio-demographic and socio-economic factors can affect smoking behaviour¹⁸. The health behaviour of immigrants may be expected to eventually reflect those of the host country’s population through acculturation, and hence smoking cessation might follow this pattern¹⁹.

Smoking-cessation interventions were first implemented in the UK by the National Health Service in 1999, when the NHS National Institute of Clinical Excellence highlighted the need to reduce the prevalence of smoking amongst ethnic minority populations²⁰. The factors that need to be taken into account in improving interventions tailored for ethnic minority groups are still disputed²¹. Convincing arguments have been made that it is important to adapt existing programmes for such groups²². Little research has been conducted on smoking within the UK Chinese population, and this might be due to a low level of bilingualism among researchers²³. In addition, the stereotyping of Chinese immigrants as ‘independent’, ‘closed’, ‘self-sufficient’ and of ‘poor English-speaking ability’²³ may also have contributed to the lack of research.

METHODS

The qualitative approach used here focuses on the views and experiences of individuals in a natural setting²⁴. The data reflect feelings, experiences and cognition that underlie and influence behaviour²⁵. A semi-structured interview was used²⁵ to ensure guidance of the discussion by the researcher²⁶. It was used to focus on experiences of participants and to identify their smoking-related cognitions²⁷.

There are about 11,000 Chinese in Glasgow²⁸, and membership of the Chinese Community Development Partnership (CCDP), a non-profit organisation supporting this community, is around 450 people of Chinese origin. A general information questionnaire was developed, in English and Chinese, to collect basic demographic information on those interviewed and semi-structured interviews employed 11 initial questions, preceded by two pilot interviews.

Potential participants were Chinese community members aged 18-65 years old, normally living in Glasgow and who were currently smokers. Purposive sampling with snowballing was used in recruitment. Signed consent was collected from all participants, while seven participants were recruited via the CCDP and a further eight by snowballing.

Qualitative data analysis software was used and the analysis involved the comparison of new data with analysed data; and the reduction of data through theme identification. Main themes and sub-themes were identified (Table 2) and verbatim quotations used to illustrate the core elements of respondents’ accounts²⁹ with the participant’s number in brackets. The study was approved by the University of Glasgow’s research ethics committee.

RESULTS

The main themes and sub-themes are presented in Table 2 and illustrative theme related interview data are presented in Box 1.

DISCUSSION

This study found that one-third of participants had tried to quit smoking while living in China, reflecting the Jiang et al.³⁰ finding that 75.6% of a sample of smokers in China had no plan to quit and 52.7% had never tried. Here, most participants reported smoking-related health problems and medical advice as the main reasons for quitting, and the latter was found to be the most commonly cited smoking-cessation trigger in China³¹. Few studies have reported the importance of physician advice for quitting in China and this may reflect the high smoking prevalence, 21%-61%, amongst Chinese physicians³².

On migration to Glasgow, most participants here had tried to quit with various triggers cited. Around two-thirds intended to quit at the time of interview; with concern for individual health and the advice from health professionals, being the top reasons cited. This may reflect UK smokers’ greater knowledge of smoking-related health risks and higher motivation to quit than their counterparts in China³³.

In the UK, cigarette-pack health warnings increased motivation to quit and were found to be more effective than equivalent Chinese warnings³⁴. Such health-risk information may be an important consideration for this community, when cessation is promoted. General practitioners (GPs) here are important in discouraging smoking, with 36% of a sample of UK smokers finding that their advice prompted quit attempts³⁵. Excessive or inflexible working hours and low confidence in smoking-cessation services led to the low interest in cessation services in the community here, and this has not been reported before. The cost of cigarettes is known to be a trigger for cessation in the UK, but is the least significant motivation to quit in China^16,36 where tobacco is cheap. A barrier to quitting here was the availability of cheaper imported Chinese cigarettes, but the link between cigarette type and cessation has not been previously well explored.

In the UK, marriage and co-habitation are significantly associated with past quit attempts^37,38. In this study, most married participants indicated that the concern for relatives was an important quit motivator on moving to Glasgow. Chinese immigrants in the UK were more aware of, and sensitive to, the risks of second-hand smoke than when in China³⁹. The impact of smoking on offspring was cited here as a quit trigger, and this has been identified⁴⁰. The collectivist culture of China may promote more consideration for others’ views in the cessation decision than individualistic cultures.

Lower nicotine dependence and higher self-efficacy have been associated with increased quit-attempt rates and long-term cessation in the UK⁴¹; here many participants reported that their lower nicotine dependence was predictive of being able to make a quit attempt. However, two males reported low nicotine dependence and a negative attitude to smoking cessation, but not to quitting. This had not been previously identified in this group, but may be of importance in cessation support.

The participants’ higher prevalence of cessation attempts on migration to Glasgow is supported by the literature, which suggests that acculturation is a considerable determinant of smoking cessation behaviour among immigrants^18,42. Two-thirds of the participants reported that Chinese immigrant smokers had adopted the UK smoking pattern, and smoking among the individual’s social circle is a well-established reason for initiation or relapse in smoking^13,43,44. One female participant reported that a colleague smoking prompted her relapse. The level of acculturation may be an issue for cessation-programme planners to consider, as will be the use of the workplace setting to promote cessation, particularly where the workforce is largely composed of Chinese immigrants. The social role of cigarette smoking among Chinese people reflects well-established social norms^39,45, and social factors were influential here in triggering relapse in participants while in the UK.

Participants rarely used smoking-cessation services in Glasgow, despite their general effectiveness⁴⁶. Uptake of NHS stop-smoking services by Chinese immigrants in 2015 was below a quarter that of other populations⁴⁷, and this may reflect doubts about pharmacotherapy and practicalities of service access^48,49. Language, distrust, and inflexibility of services were barriers to cessation-service use; and Liu et al.⁵⁰ emphasized that high-quality language interpretation must be professional and trusted, to enable access to cessation services.

Most participants did not access cessation services to which they had been referred to by their GPs. Several reported that discussion with a GP had prompted a quit attempt, but this became impractical due to their long working hours; similar findings exist in the literature⁵¹. Chinese smokers in the UK were mainly unaware of NHS smoking-cessation services, and this emphasizes the significance of developing culturally-appropriate measures to increase awareness and access to cessation¹⁷.

The use of community resources can dramatically increase accessibility⁵² through the development of trust. Community lay health workers may be effective in improving the uptake of cessation services⁵³, and participants here believed that bilingual promotional information on cessation services was essential in building good relationships with the local Chinese community. Using and evaluating community resources to increase accessibility might be regarded as a useful basic principle for cessation-service planners to consider⁵².

Compatibility of health-promotion information with the belief system of targeted populations plays an important role in enabling attitudinal and behavioural changes related to smoking⁵² ; resolving smokers’ distrust of services poses a challenge for health promoters⁵¹. Here, most participants reported no confidence in cessation preparations, believing personal willpower as a more effective approach. To be more effective in assisting Chinese smokers to quit, it is essential for service providers to understand cultural values related to cigarette smoking⁵³.

CONCLUSIONS

Improving health information and education among Chinese community members in Glasgow may be important in improving cessation-services uptake. Improved language support should be considered, including the use of Chinese and English in promotional material, together with the targeting of families and groups that could support smokers to quit. Improved information relating to pharmacotherapy may increase nicotine-replacement-therapy uptake, as might be the use of Chinese community resources to promote cessation. A settings approach to cessation, and consideration of the antisocial hours of work, common in the catering industry, may improve cessation-service engagement.